Provider Demographics
NPI:1225301559
Name:ROTHENSTEIN, BRYAN RUSSELL (LMSW)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:RUSSELL
Last Name:ROTHENSTEIN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6127 224TH ST
Mailing Address - Street 2:APT A
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2331
Mailing Address - Country:US
Mailing Address - Phone:917-608-5763
Mailing Address - Fax:
Practice Address - Street 1:22005 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-2140
Practice Address - Country:US
Practice Address - Phone:718-740-5000
Practice Address - Fax:718-479-0200
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084913104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker